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OBJECTIVE: The addition of spiral computed tomography (SCT) to bedside assessment in patients with major trauma may improve detection of significant injury. We hypothesized that in high-acuity trauma patients, emergency physicians' ability to detect significant injuries based solely on bedside assessment would lack the sensitivity needed to exclude serious injuries when compared with SCT. METHODS: This was a prospective single-cohort study of high-acuity trauma patients routinely undergoing whole-body SCT at a level 1 trauma center from January to September 2006. Before SCT, emergency physicians assigned ratings for likelihood of injury to 5 body regions on the basis of bedside assessment. These ratings were compared with final SCT interpretations. RESULTS: We enrolled 400 patients as a convenience sample; 71 were excluded. When a "very low" rating was considered negative and "low," "intermediate," "high," and "very high" were considered positive, emergency physicians were able to detect head, cervical spine, chest, abdominal/pelvic, and thoracic/lumbar spine injuries with sensitivities (95% confidence interval) of 100% (98.6%-100%), 97.4% (94.9%-98.8%), 96.9% (94.2%-98.4%), 97.9% (95.5%-99.1%), and 97.0% (94.3%-98.5%), respectively. For overall diagnostic accuracy, areas under the receiver operating characteristics curve (95% confidence interval) were 0.87 (0.82-0.92), 0.71 (0.62-0.81), 0.81 (0.76-0.86), 0.77(0.71-0.83), 0.74 (0.65-0.84), respectively. CONCLUSIONS: Bedside assessment by emergency physicians before SCT was sensitive in ruling out serious injuries in high-acuity trauma patients with a "very low" rating for injury. However, overall diagnostic accuracy was low, suggesting that SCT should be considered in most high-acuity patients to prevent missing injuries.

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OBJECTIVES: The aim of this study was to identify factors other than work hours in the emergency department (ED) work environment contributing to resident stress. METHODS: This study involved a prospective cohort evaluation of emergency medicine residents in the ED. Twelve surveys were collected from 18 subjects, 4 each from the day, evening, and night shifts. The Perceived Stress Questionnaire and a visual analog stress scale were administered. Data collected included the shift number of a given consecutive sequence of shifts, number of procedures performed, number of adverse events, average age of the patients seen by the resident, triage nurse-assigned acuities of the patients seen by the resident during the shift, the number of patients seen during a shift, the number of patients admitted by the resident during the shift, anticipated overtime after a shift, and shift-specific metrics related to overcrowding, including average waiting room time both for the individual residents and for all patients, average waiting room count for all patients, and average occupancy of the ED for all patients. RESULTS: Among the 216 studied shifts, there was considerable variability in stress both within and between residents. In the multivariate mixed-effect regression analysis, only anticipated overtime and process failures were correlated with stress. Factors related to ED overcrowding had no significant effect on resident stress. CONCLUSIONS: Resident stress was most impacted by anticipation of overtime and adverse events. Overcrowding in the ED and traditional measures of workload did not seem to affect stress as much.

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STUDY OBJECTIVE: The primary intention of spiral computed tomography (SCT) in trauma patients is to identify significant injuries. However, unanticipated information is often discovered. We hypothesize that SCT often identifies clinically significant incidental findings in trauma patients. METHODS: This was a retrospective protocol chart review of consecutive adult trauma patients seen at a level I trauma center. A complete SCT was defined as computed tomography imaging of the head, cervical spine, chest, abdomen, and pelvis, thoracic, and lumbar spine. Incidental findings were classified into 2 categories: type 1, which requires urgent evaluation, and type 2, which requires informing the patient but does not mandate urgent follow-up. RESULTS: We reviewed 3246 patient charts and 3092 met inclusion criteria. Type 1 findings were reported in 990 (32.0%; 95% confidence interval [CI], 30.4%-33.7%) patients. Type 2 findings were found in 1274 (41.2%; 95% CI, 39.5%-42.9%) patients. Female sex (odds ratio, 1.38; 95% CI, 1.16-1.65) and older age (odds ratio, 2.61; 95% CI, 2.33-2.93) were independently associated with a higher prevalence of type 1 findings. There were 631 incidental findings concerning for neoplasm, which included 196 pulmonary nodules, 99 liver, 36 renal, 23 brain, and 11 breast masses. CONCLUSIONS: A significant number of trauma patients evaluated with SCT are diagnosed with potentially serious incidental findings. For long-term care and medicolegal concerns, physicians need to inform patients of these incidental findings and the need for further evaluation.

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OBJECTIVE: No study to date has addressed whether confirmatory x-ray after ED percutaneous feeding tube (PFT) replacement is always necessary. We hypothesized that x-ray confirmation of PFT replacement is not necessary in patients lacking both tract immaturity and trauma to the tract during dislodgement or replacement. Therefore confirmatory x-rays could safely be avoided for these patients. METHODS: Medical records of 113 adult PFT encounters that met inclusion criteria between December 2000 and March 2004 at an urban university hospital ED seeing approximately 50,000 adult patients per year were reviewed. RESULTS: Ninety-four patients (83%) presented secondary to dislodgement, and 19 patients (17%) presented secondary to malfunction. Forty-seven patients (42%) did not have confirmatory x-rays, and 66 (58%) had confirmatory x-rays. None of the patients discharged without a confirmatory x-ray returned with evidence of improper PFT placement. Of the 66 patients who had a confirmatory x-ray, 62 (94%) x-rays showed the feeding tube was in the correct location. In 4 patients, the x-ray showed either the PFT was not in the stomach or evidence of tract compromise. All of these patients had trauma to the tract and 3 of 4 were in immature tracts. There were only 19 patients of the total group of 113, however, who had neither trauma nor an immature tract. CONCLUSION: Although uncommon, significant problems with PFT placement occur with the potential for catastrophic consequences. It appears that immaturity of the tract and trauma to the tract, either potential or actual, are the major risk factors for such complications.

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To determine, in an Emergency Department (ED) population, the incidence of pneumonia diagnosed on thoracic computed tomography (CT) in the setting of negative or non-diagnostic chest radiographs (CXR). This is a retrospective chart review of all ED visits of adult patients ultimately diagnosed with "pneumonia" in whom both CXR and CT were obtained. We note cases in which the CXR was either negative or non-diagnostic for pneumonia and the CT noted a definitive infiltrate consistent with pneumonia. Of the 1,057 patients diagnosed with pneumonia, both CXR and CT were performed in 97 cases. Of this group, there were 26 patients (27%), in whom the CXR was either negative or non-diagnostic, but the CT noted an infiltrate/consolidation consistent with pneumonia. In our retrospective review of ED patients, we find that in 27% of cases in which both a CXR and a CT scan were performed in the work-up of varied chief complaints, pneumonia was demonstrated on CT in the face of a negative or non-diagnostic CXR. This analysis demonstrates the need for further studies regarding the appropriate radiographic evaluation of pneumonia, particularly in high-risk patients.

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Ovarian vein thrombosis (OVT) is a rare cause of abdominal pain that may mimic a surgical abdomen. The differential diagnosis of OVT includes acute appendicitis, endometritis, pelvic inflammatory disease, pyelonephritis, nephrolithiasis, tubo-ovarian abscess, and ovarian torsion. The complications of OVT, including sepsis and pulmonary embolism, are significant. Diagnosis relies on a careful examination of the radiographic findings. This diagnosis should be considered not only in postpartum patients but also in women with pelvic inflammatory disease, recent abdominal surgery, malignancy, or known hypercoagulable state. In this report we present a case of OVT in a 29-year-old woman presenting with 3 days of sharp left-sided abdominal pain, nausea, and vomiting after bilateral salpingectomy. We then discuss the epidemiology, pathophysiology, and clinical management of OVT.

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BACKGROUND: The objective of this study was to compare patients' preferences and physicians' practice for the presence of chaperones during genitourinary examinations. METHODS: A survey of 163 emergency department patients and 52 physicians was used to evaluate patients' preferences and physicians' practices for the presence and gender of a chaperone during genital examinations. RESULTS: Most male patients (88%) did not care about the presence of a chaperone. Only 47% of female patients preferred a chaperone when a pelvic examination was to be performed by a male physician and only 26% preferred a chaperone with a female physician. One hundred percent of male and most female physicians (92%) used a chaperone for pelvic examinations. Most physicians do not ask patients whether they want a chaperone; however, most patients would like to be asked. CONCLUSIONS: We conclude there is a discrepancy between what physicians do and what their patients desire.

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PURPOSE: The purpose of this study was to see if there is a significant association between calcium-phosphorus product (CPP) and initial troponin-T values in patients with renal insufficiency. BASIC PROCEDURES: A retrospective study over 4 months from the laboratory database of all patients with serum creatinine values greater than 3 mg/dL who had concomitant troponin T and creatine kinase isoenzymes measured was conducted. The most recent calcium and phosphorus values were also abstracted. RESULTS: There were 87 patients with a mean age of 59 years, a median creatinine value of 51 mg/dL, a mean CPP of 47, and a median initial troponin-T value of 0.18 ng/mL. The troponin level was elevated (>0.05 ng/mL) in 74% of the patients. The CPP was higher than 55 in 28% of the patients. When comparing the troponin values with the CPP, there was no association noted (P = .72). CONCLUSIONS: Although both elevated CPP and troponin values are associated with increased cardiovascular mortality in the intermediate term, we could not demonstrate a useful relationship between the 2 values that would indicate causality or help with the interpretation of the initial troponin level when patients with renal insufficiency present with suspected acute myocardial infarction.

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OBJECTIVE: The objective of this study was to assess attitudes of patrons and medical school faculty about physicians with nontraditional facial piercings. We also examined whether a piercing affected the perceived competency and trustworthiness of physicians. DESIGN: Survey. SETTING: Teaching hospital in the southeastern United States. PARTICIPANTS: Emergency department patrons and medical school faculty physicians. INTERVENTIONS: First, patrons were shown photographs of models with a nontraditional piercing and asked about the appropriateness for a physician or medical student. In the second phase, patrons blinded to the purpose of the study were shown identical photographs of physician models with or without piercings and asked about competency and trustworthiness. The third phase was an assessment of attitudes of faculty regarding piercings. MEASUREMENTS AND MAIN RESULTS: Nose and lip piercings were felt to be appropriate for a physician by 24% and 22% of patrons, respectively. Perceived competency and trustworthiness of models with these types of piercings were also negatively affected. An earring in a male was felt to be appropriate by 35% of patrons, but an earring on male models did not negatively affect perceived competency or trustworthiness. Nose and eyebrow piercings were felt to be appropriate by only 7% and 5% of faculty physicians and working with a physician or student with a nose or eyebrow piercing would bother 58% and 59% of faculty, respectively. An ear piercing in a male was felt to be appropriate by 20% of faculty, and 25% stated it would bother them to work with a male physician or student with an ear piercing. CONCLUSIONS: Many patrons and physicians feel that some types of nontraditional piercings are inappropriate attire for physicians, and some piercings negatively affect perceived competency and trustworthiness. Health care providers should understand that attire may affect a patient's opinion about their abilities and possibly erode confidence in them as a clinician.

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